Peds: Chap.16 Motor Learning + Chap.29 Cerebral Palsy

Guiding Theories

Top-Down Approach

• Focus: Start with the child’s daily activities and participation (big picture), then address underlying skills.

• Goal: Improve function in meaningful contexts (e.g., play, school, home).

Dynamic Systems Theory

• Core Idea: Movement and behavior emerge from the interaction of multiple systems (e.g., sensory, motor, cognitive).

• Key Points:

  • No one system controls action.

  • Skills develop through practice in real-life contexts.

  • Therapy should offer varied, meaningful experiences.

Ecological Theory

• Core Idea: Child’s development is influenced by the environment and relationships.

• Key Points:

  • Emphasizes fit between child and environment.

  • Modify surroundings to support success.

  • Collaborate with family, school, and community.

Dynamical Systems Theory

Movement Depends On:

• Task characteristics

• Interaction of systems (motor, sensory, cognitive)

• Individual, task, and environment working together

Dysfunction:

• Occurs when the child’s movement lacks flexibility or adaptability

• The child cannot meet task demands or adjust to environmental constraints

Ecological Theory

• Focus: How children perceive and act within their environment during real-world activities

• Key Concept: Perception guides action in context (e.g., a child sees a step and prepares to climb)

Gibson’s Ecological Theory Concepts:

• Agency: Child knows they can control actions and cause effects (e.g., pressing a button makes a toy light up)

• Prospectivity: Ability to anticipate and plan movements (e.g., reaching before grabbing)

• Behavioral Flexibility: Adjusting actions to new or changing environments (e.g., climbing different playground structures)

Whole Learning (Dynamic Systems Theory)

• Learning the entire task is more effective than breaking it into parts.

• Promotes better performance and efficiency in children.

• Engages multiple systems (motor, cognitive, sensory) at once.

• Reflects real-life activities and supports generalization.

The Process of Motor Learning

Transfer of Learning

• Skills practiced in one setting can transfer to similar tasks or environments.

• Best when practiced in natural contexts.

Sequencing & Adapting Tasks

• Start with simple → complex

• Use familiar tasks first

• Adapt difficulty based on child’s needs and progress

Practice Types

• Massed Practice: Repeated trials with little rest (good for early skill learning)

• Distributed Practice: Practice with rest between trials (better for fatigue and retention)

• Variable/Random Practice: Practicing tasks in different ways or orders (enhances generalization)

Feedback

• Intrinsic: Comes from within the child (e.g., feeling balance shift)

• Extrinsic: Provided by someone else (e.g., verbal cue from therapist)

Types of Extrinsic Feedback

• Demonstrative: Showing how to do the task

• Knowledge of Performance (KP): Info about how the movement was done (e.g., "You kept your back straight!")

• Knowledge of Results (KR): Info about the outcome (e.g., "You got the ball in the basket!")

Practice Models Using Dynamic Systems Theory

1. Model of Human Occupation (MOHO)

• Focuses on motivation, habits, roles, and performance.

• Emphasizes the interaction of the person, environment, and occupation over time.

• Supports dynamic change through volition and adaptation.

2. Person–Environment–Occupation–Performance (PEOP)

• Highlights the fit between person, environment, occupation, and performance.

• Function occurs when all systems interact smoothly; dysfunction when one or more are disrupted.

3. Occupational Adaptation (OA)

• Focuses on the person’s ability to adapt when faced with occupational challenges.

• Success = ability to respond to demands with meaningful, flexible action.

4. Canadian Model of Occupational Performance and Engagement (CMOP-E)

• Emphasizes the dynamic relationship between person, occupation, and environment.

• Core: Spirituality as the motivator of occupation

• Goal: Enable engagement and performance through environmental fit and occupational choice.

Task-Specific Training

Task-Specific Training

• Focuses on real tasks that are meaningful to the client

• Practice is repetitive and done in the actual context

• Random sequencing of tasks improves transfer

• Goal: Client completes the entire task, not just parts

• Use positive reinforcement to boost motivation and engagement

Cerebral Palsy 

• Permanent disorders of development of movement and posture

• Cause activity limitations

• Disturbances of sensation, perception, cognition, communication, and behavior

• Associated damage to brain

• Epilepsy and secondary musculoskeletal problems

Common Symptoms in Children With Cerebral Palsy

Posture & Postural Control

• Posture: Alignment of body parts in relation to each other and the environment

• Postural Control: Ability to maintain or adjust posture for balance and movement

• Essential for functional activities like sitting, reaching, walking

Atypical Movement Patterns

• May result from neuromuscular impairments

• Includes poor alignment, limited movement, or reliance on compensatory strategies

• Often linked to abnormal muscle tone and delayed motor milestones

Muscle Tone Distribution & Classifications

• Monoplegia: One limb affected

• Hemiplegia: One side of the body (arm & leg)

• Paraplegia: Both lower limbs

• Quadriplegia/Tetraplegia: All four limbs (used interchangeably, but "tetraplegia" is more common in pediatrics)

Cerebral Palsy: Types

1. Spastic CP

• Most common type

• Characterized by increased muscle tone (hypertonia)

• Movements are stiff and jerky

• May affect one or more limbs (e.g., hemiplegia, diplegia)

2. Dyskinetic CP

• Includes athetosis, dystonia, and chorea

• Movements are involuntary, uncontrolled, and variable

• Often worsens with stress or voluntary movement

  1. Athetoid CP

  • Characterized by slow, writhing movements

  • Often affects hands, feet, arms, or legs

  • Muscle tone fluctuates between hypertonia and hypotonia

  • Trouble maintaining posture and stability

  2. Dystonic CP

  • Twisting and repetitive movements or abnormal postures

  • Can involve sustained muscle contractions

  • May appear more rigid or stiff than athetoid

  3. Ataxic CP

• Involves poor coordination, balance, and depth perception

• Movements are shaky or unsteady, especially during voluntary tasks

4. Mixed CP

• Combination of two or more types, commonly spastic + dyskinetic

• Symptoms vary based on areas of brain injury

Upper Limb Function Challenges

1. Abnormal Muscle Tone

• Can be spastic (tight), fluctuating, or low tone

• Impacts coordination, control, and timing of movement

2. Decreased Postural Stability

• Poor core/trunk control affects arm and hand use

• Difficulty maintaining balance while reaching or using hands

3. Contractures

• Permanent muscle/tendon shortening from disuse or spasticity

• Limits joint movement (e.g., wrist, elbow, fingers)

4. Impaired Hand Performance

• Challenges with grasp, release, and manipulation

• Impacts fine motor tasks like writing, buttoning, feeding

Secondary Impairments

• Chronic Pain – Due to spasticity, contractures, poor positioning

• Intellectual Impairment – Varies from mild to severe

• Unable to Walk – Especially in higher GMFCS levels (IV–V)

• Hip Displacement – Due to muscle imbalances and poor alignment

• Speech Deficits – From oral-motor and respiratory coordination issues

• Epilepsy – Seizure disorders commonly co-occur

• Behavioral Disorders – Anxiety, aggression, or self-injury may occur

• Bladder Incontinence – Neurogenic bladder or lack of awareness

• Sleep Disorders – Trouble falling/staying asleep; common in CP

• Vision Impairment – Including strabismus or cortical visual impairment

• Inability to Eat Orally – May require G-tube or alternative feeding

• Hearing Impairment – Can impact language development

• Sensory Processing Issues – Over- or under-responsive to sensory input

Manual Ability Classification System (MACS)

Purpose:

• Classifies how children with cerebral palsy use their hands to handle objects in everyday activities.

Target Population:

• Children ages 4–18 with cerebral palsy.

Focus:

• Measures typical manual performance, not their best ability.

• Assesses independence, efficiency, and the need for assistance with daily tasks.

MACS Levels:

Level	Description
I	Handles objects easily and successfully.
II	Handles most objects but with reduced quality or speed.
III	Handles objects with difficulty; needs help to prepare or modify activities.
IV	Limited ability to handle objects; relies on others most of the time.
V	Does not handle objects; completely dependent on others.

Medical-Based Interventions

• Manage spasticity

  • Botox

  • Baclofen

  • Surgeries

Occupational Therapy Intervention

Movement is complex and multidimensional

• Involves the interaction of sensory, motor, cognitive, and environmental systems.

Motor Control vs. Motor Learning

• Motor Control: Ability to regulate and direct movement.

• Motor Learning: How movement skills are acquired and refined over time through practice and feedback.

Intervention Approaches and Tools

Adaptive Equipment

• Devices that support participation and independence (e.g., built-up handles, seating systems).

Orthotics

• Braces or splints that improve positioning, function, and prevent contractures.

Constraint-Induced Movement Therapy (CIMT)

• Restrains the unaffected limb to encourage use of the affected one.

• Used for children with hemiplegia.

Bimanual Therapy

• Encourages use of both hands to improve coordination and functional use in daily tasks.

Physical Agent Modalities (PAMs)

• Use of heat, cold, or electrical stimulation to prepare muscles for activity (used with caution in pediatrics).

Therapeutic Taping and Strapping

• Kinesiology tape or rigid strapping to support joints, improve alignment, and assist with movement patterns.

Positioning and Handling

• Techniques used to support posture and movement during play or ADLs.

• Important for stability, alignment, and access to function.

Neurodevelopmental Treatment (NDT)

• Hands-on approach to facilitate normal movement patterns and inhibit abnormal tone or reflexes.

• Emphasizes individualized handling based on movement analysis.

Cerebral Palsy Overview (Simplified Notes)

• CP is classified by:

  • Distribution: monoplegia, hemiplegia, paraplegia, quadriplegia, tetraplegia

  • Type: spastic, dyskinetic, ataxic, mixed

• Lesions occur in the immature brain, which may cause:

  • Changes in motor development over time

  • Secondary impairments: skin issues, breathing problems, vision/hearing/speech impairments

• OTs use occupation-centered models focusing on:

  • Child’s abilities, interests, and motivation

  • Environment (supports/barriers)

  • Task demands

• Children with CP often have:

  • Poor postural control and difficulty moving against gravity

  • Abnormal muscle tone, affecting coordination and smooth movement

  • Tone can be influenced by alertness, fatigue, or emotions

• Movement difficulties impact daily activities, including:

  • Feeding, dressing, hygiene, academics, and play

• Evidence-based interventions for CP include:

  • Functional, goal-directed training

  • Constraint-Induced Movement Therapy (CIMT)

  • Bimanual training

  • Fitness programs

  • Home exercise programs (HEP)

  • OT after botulinum toxin (Botox) injections

• OT’s role: Plan and carry out interventions that promote function and independence